Transferring Hospitals

For staff at hospitals who transfer their patients to our Trauma Center, you may request updated information regarding the status of adult patients by filling out our Transferring Hospital Request Form below.

Please note: this form is only for staff of transferring hospitals to request the status of adult patients. It is not intended for use of patients or friends or family members of patients.

Requester's Information

First

Middle

Last

Suffix

E-mail

Phone

Transferring hospital

Patient's Information

First

Middle

Last

Date of Birth

Date must be entered as MM/DD/YYYY.

Date of Service

Date must be entered as MM/DD/YYYY.

Comments/Questions/Request

I have another request

First

Middle

Last

Date of Birth

Date must be entered as MM/DD/YYYY.

Date of Service

Date must be entered as MM/DD/YYYY.

Comments/Questions/Request

Confidential – Peer Review Protected Wisconsin State Statute 146.56

All records, data, and information collected and then maintained for trauma care quality/performance improvement are to be used strictly for peer/professional review as defined by WI Stat 146.38 and 146.56. Data, records and knowledge, including minutes, collected for or by individuals to committees assigned peer/quality review functions are confidential in accordance with DHS 118.10 and WI Stats 146.38 and 146.56.

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